Question: The radiologist documented an ultrasound-guided aspiration of right upper quadrant perihepatic fluid collection. "A 20-gauge needle was advanced into the perihepatic fluid collection with difficulty. A wire could not be passed into this collection raising the suspicion that the collection may be in part solid. A 5 French catheter was placed. A few drops of bile appearing material was aspirated. Therefore, a wire was passed into the collection and a 6.5 French drain was placed. The catheter was placed to gravity drainage. Less than 1 cc of bilious fluid could be aspirated and was sent for culture and bilirubin." Should I report 49020 and 75989?
Answer: Your best bet is to report 49021 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous) because the catheter was left indwelling.
You may report the ultrasound guidance separately using 75989 (Radiological guidance [i.e., [...]